Executing change in the management of chronic kidney disease: perspectives on guidelines and practice.

In this era of escalating information, costly technology, and an increasing prevalence of chronic complex diseases in an aging population, a systematic approach to execute changes in the care of patients with kidney disease must be developed. Specifically, there is a need to facilitate the translation of research and clinical guidelines into the delivery of quality clinical care. At present in nephrology, there is some knowledge of disease processes, accumulating knowledge about risk factors for progression, and knowledge about how to best deliver care to those with a chronic disease. The current health care environment is not suited to either the care of chronic conditions or to prevention. Information technology should facilitate shared models of care delivery for chronic conditions and allow opportunities to add new knowledge and deliver good care to complex patient groups. To execute change in the management of patients with CKD, medical students, healthcare professionals, and established physicians need to be educated about the prevalence and consequences of CKD. These educational initiatives should be done in the context of cases or specific patients especially for established practitioners, and should be simplified to make analogies to familiar concepts. The concept that CKD is a risk factor for cardiovascular disease, and needs to be managed (as does diabetes and dyslipidemia), should be more clearly articulated. Basic and clinical research in kidney disease has been enhanced by discoveries in vascular biology, diabetes, and cardiology. Much of the clinical research has been limited, however, by lack of clear definition of CKD. The development of the new K/DOQI staging system that defines and classifies the severity of kidney disease may improve the execution of ongoing robust clinical trials. Incorporating this classification system into the clinical practice of all physicians by automatic laboratory reporting of estimates of GFR raises awareness and improves communication between all medical professionals. Collaborative management of CKD patients between different physicians and multidisciplinary teams, in conjunction with the ongoing investigation of treatments and treatment strategies by both clinician and researchers, may well lead to improved outcomes for patients with CKD. Executing change in the management of CKD requires an increased awareness on the part of all clinicians, including nephrologists, regarding the prevalence and importance of the problem of earlier stages of kidney disease. The systematic evaluation of all patients and incorporation of simplified definitions and classification systems should enhance the ability to improve the outcomes of patients with kidney disease irrespective of time of identification.